LOCAL BANKRUPTCY FORM NO. 5 IN THE UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF PENNSYLVANIA CHAPTER 13 BUSINESS CASE QUESTIONNAIRE

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1 LOCAL BANKRUPTCY FORM NO. 5 IN THE UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF PENNSYLVANIA CHAPTER 13 BUSINESS CASE QUESTIONNAIRE Local Rule requires Chapter 13 Debtors that are self-employed (including Debtors acting as landlords), to complete and submit this Questionnaire to the Trustee along with all documents set forth in the Checklist which follows the signature page of the Questionnaire. You must answer all items in the Questionnaire. Use a separate page if additional room is needed, but be sure to reference the additional page next to the item you are answering. All information must be complete and organized. Failure to provide detailed and accurate information may result in the Trustee filing a motion to dismiss your case. You must send this completed Questionnaire along with all required attachments to Ronda J. Winnecour, Trustee, U.S. Steel Tower, Suite 3250, 600 Grant Street, Pittsburgh, PA so that it reaches the Trustee at least 15 14* days prior to your first scheduled meeting of creditors. If you fail to do so, the Trustee may require your appearance at an additional meeting or file a motion to dismiss your case. Do Not File this Questionnaire with the Clerk of the Bankruptcy Court The Questionnaire must be dated. The Questionnaire must contain the original signature of all Debtors in the case. A copy of the Questionnaire should be kept by the Debtor for future reference. If you have questions concerning this Questionnaire, please contact your attorney. Debtor (s) Name(s) _ Chapter 13 Case # Name of Business List all past names used by Business Location where business is operated Description of Business Activities/Type of Business What circumstances led you to file this bankruptcy? _ How do you expect these circumstances to change so that you will be able to fund a Chapter 13 Plan? _ * As amended in General Order # and # , effective December 1, 2009.

2 1. Type of Business Organization, circle one: Corporation Sole Proprietorship Partnership Other Has business ever been incorporated? Yes Date business began Federal ID number (if applicable) State ID number 2. If your business is a Partnership, please answer (a) to (c) below: (a) Names of Partners (b) Percentage of your ownership: Debtor % Joint Debtor % (c) Is there a written partnership agreement? Yes If yes, please include a copy of the agreement with this Questionnaire when you return it to the Trustee. 3. If your business is a Corporation, please answer (a) to (g) below: (a) Who are the shareholders? (b) How many shares have been issued and are outstanding? (c) What is your percentage ownership? Debtor % Joint Debtor % (d) State of incorporation _ (e) Is the corporation in good standing with the Secretary of State? Yes If no, why not? (f) Fair Market Value of Corporate Assets, including going concern value $ Basis of value (g) Amount of Corporate Debts $_ 4. Is the business cyclical? Yes If yes, when is the busy season? If yes, when is the slow season?

3 5. Do you have an accountant or bookkeeper? Yes If yes, please provide the name, address and phone number of this individual _ Do you understand that you are required to file monthly operating reports with the Court and serve the Trustee with a copy by the 15th of each month that you are in bankruptcy? Yes 6. Are all tax returns which should have been filed to this point in time filed? Yes If no, list years that are delinquent, type of return owed, and entity to which return is owed: Year Entity(s) and Type of Return Due Do you understand that while you are in Chapter 13, you are individually responsible for keeping current with all of your post-petition business as well as personal tax obligations? Yes Do you understand that the Court in this District has entered a General Order which requires all delinquent tax returns to be filed within 60 days from the date that you filed your bankruptcy case? Yes 7. Have you filed estimated quarterly income tax returns with the IRS? Yes If yes, please provide copies of the last 3 estimated returns filed, with proof of payment. If no, explain why not 8. Does the business have employees? Yes If yes, how many? Are any of these persons related to you? Yes Does the business withhold from their wages? Yes If yes, where do you deposit the withholdings and how often? i. ii. Please provide copies of proof of payment of employee withholding taxes for the 3 months prior to the month that your case was filed.

4 Do you understand that you must keep the withholding funds separate from your general operating funds? Yes No If you do not withhold, how are the employees compensated? Do you have subcontractors? Yes Are 1099s issued? Yes 9. Is your business required to collect sales tax? Yes If yes, has your business collected and remitted sales taxes on a regular basis? Yes No If no, explain why Do you understand that you must keep the sales tax funds separate from your general operating funds? Yes Please provide copies of proof of payment of sales taxes for 3 months prior to the month your case was filed. 10. Are you leasing office space? Yes If yes, answer (a) to (e) below: (a) Address of Property (b) Landlord s Name and Address (c) Monthly Rental Payment $ (d) Term of lease (e) Do you wish to continue the lease? Yes 11. Does the business lease business equipment or autos? Yes If yes, answer (a) to (e) below: (a) Description of leased/rented items? (b) Person or entity s name and address from which items are rented or leased

5 (c) Payment terms _ (d) Term of lease (e) Do you wish to continue the lease? Yes 12. Does the business have any outstanding contracts? Yes If yes, please describe 13. If you rent real property owned by you to others, please complete the following: Address of Tenant Date Lease Began Date Lease Ends Amt. Monthly Rent 14. Is the business required to have any business licenses or permits? Yes If yes, please list: If yes, are licenses/permits current? Yes 15. Does the business carry the following insurance policies? Commercial Liability? Yes No Policy No. Exp. Date Workmans Compensation? Yes No Policy No. Exp. Date Fire Building? Yes No Policy No. Exp. Date Fire Contents? Yes No Policy No. Exp. Date Automobile Coverage? Yes No Policy No. Exp. Date Liquor liability? Yes No Policy No. Exp. Date List Others Are all policies current? Yes List insurance agency(s)

6 Do you know that in order to continue the operation of your business, it is your responsibility to obtain and maintain comprehensive liability insurance for the operation for your business? Yes 16. Does the business keep inventory on hand? Yes If yes, what would you estimate the market value of your inventory to be? $ When was the last physical count of your inventory? What was the value of the inventory at that time? $ Please provide a list of your inventory. 17. What is the balance of the business accounts receivable? $ What amount of the receivables is reasonably collectible? $ Please provide a copy of your accounts receivable ledger. Have you pledged your receivables, rents, profits, or other cash as collateral for any loans? Yes If yes, please identify Do you understand that if you have borrowed money from any creditor and as security or collateral for the loan you have pledged accounts receivables, rents, or other cash, you may not use the accounts receivables, rents or cash without express written consent from the Creditor, or an order from the Bankruptcy Court allowing the use? Yes 18. If you were to buy your business today, how much would you pay for it? $ I/We declare under penalty of perjury that the foregoing statement of information is true and correct to the best of my/our knowledge, information, and belief. Dated: Debtor s signature _ Joint Debtor s signature

7 CHECKLIST OF DOCUMENTS THAT MUST BE RETURNED WITH YOUR QUESTIONNAIRE You must send copies of the following documents to Ronda J. Winnecour, the Trustee, along with your completed Questionnaire within 15 14* days before the first scheduled 341 meeting date. Failure to do so may cause the Trustee to require your attendance at an additional meeting or file a motion to dismiss your case. Operating statements showing income and expenses for the business for the twelve (12) months prior to the time of filing your bankruptcy case. Bank statements for all accounts for the twelve (12) months prior to the time of filing your bankruptcy case. Federal income tax returns with all accompanying schedules for the two years prior to filing your bankruptcy case. State income tax returns with all accompanying schedules for the two years prior to filing your bankruptcy case. Appraisals or other third party valuations of real estate, equipment, inventories and other business property listed in your bankruptcy schedules. Financial statements furnished to third parties such as banks and trade creditors within the two (2) years prior to filing your bankruptcy case, including but not limited to the balance sheet, income statement and cash flow statement. Current schedule of accounts receivable and accounts payable. Current insurance policies that cover the assets listed in your bankruptcy schedules. The business s check register for the three (3) months prior to filing your bankruptcy case. If your business has employees, proof of payment of employee withholding taxes for the 3 months prior to the month your case was filed. If your business is required to collect and remit sales taxes, proof of payment of sales taxes for the 3 months prior to the month your case was filed. The last three federal quarterly income tax returns with proof of payment. Any partnership agreement that exists. List of your inventory and equipment. * As amended in General Order # and # , effective December 1, 2009.

8 MONTHLY OPERATING REPORT FOR CHAPTER 13 CASES Debtor s name _ Case No. _ Month Year Gross receipts for month: (If more than one source, list each) Business expenses paid: Description TOTAL GROSS RECEIPTS: Amount TOTAL EXPENSES: $ $ NET PROFIT OR (LOSS) FOR MONTH: $ Reports for each month are due by the 15th day of the following month and should be mailed to: Chapter 13 Trustee, U.S. Steel Tower, Suite 3250, 600 Grant Street, Pittsburgh, PA USE ADDITIONAL SHEETS IF NEEDED

9 BANKRUPTCY RULE 2015 AND SECTION 1304 (c) DUTY OF CHAPTER 13 DEBTORS ENGAGED IN A BUSINESS TO KEEP RECORDS, MAKE REPORTS AND GIVE NOTICE OF CASE Bankruptcy Rule 2015 and Section 1304 (c) of the Bankruptcy Code requires debtors engaged in business that file a Chapter 13 bankruptcy petition to: Keep a record of receipts and the disposition of money and property received. File with the Court, the Trustee, and with any governmental unit charged with responsibility for collection or determination of any tax arising out of such operation, periodic reports and summaries of the operation of the business, including a statement of receipts and disbursements, which shall include a statement, if payments are made to employees, or the amounts of deductions for all taxes required to be withheld or paid for on behalf of employees and the place where these amounts are deposited. As soon as possible after the commencement of the case, give notice of the case to every entity known to be holding money or property subject to withdrawal, including every bank, savings or buildings and loan association, public utility company, and the landlord with whom the debtor has a deposit, and to every insurance company which has issued a policy having a cash surrender value payable to the debtor, except that notice need not be given to any entity who has knowledge or has previously been notified of the case.